Oral triptans may not be the optimal therapy in the presence of migraine-associated gastroparesis because these agents rely on gastric motility and gastrointestinal absorption and may be ineffective or slowly or inconsistently effective in the presence of gastroparesis. Similarly, nasal spray preparations are not wholly absorbed in the nasal passages. Sprays

often enter the Galunisertib in vitro nasal pharynx and are swallowed, so they, too, depend in part on gastrointestinal absorption. Most of the therapeutic challenges presented by gastrointestinal signs and symptoms of migraine relate to the impact of these signs and symptoms on drug delivery. Nausea delays drug delivery by causing patients to delay taking oral medications. Gastroparesis delays drug delivery via an impact on drug absorption. Vomiting prevents drug delivery through expulsion of medication. Nonoral drug delivery routes that negate or minimize the impact of gastrointestinal signs and symptoms Y 27632 should be useful in overcoming these challenges. The choice of nonoral drug delivery routes should be customized to the individual patient and migraine attack. Strengths and limitations of triptan delivery systems are listed in the Table.[12] Sumatriptan injection is rapidly effective but appears to have a greater side effect burden than other triptan formulations[12] – probably because the injection produces higher maximal concentrations

than the other forms. Moreover, many patients dislike using injections. Triptan nasal sprays, besides relying in part on gastrointestinal absorption, have a bitter taste, which can be particularly adverse for patients experiencing nausea and/or vomiting.[12] The bitter or bad taste can lead the patient to delay or avoid treatment. Health care providers need to work with their patients to address the still-all-too-frequent problem of treatment failure in migraine. First, health care providers need to have greater appreciation of the importance of nausea, vomiting, and gastroparesis as Farnesyltransferase factors affecting

migraine prognosis and treatment success. Second, health care providers need to systematically assess migraine patients for gastrointestinal signs and symptoms. Finally, patients and health care providers need to be willing to practice customized migraine care, in which patients tailor the treatment and formulation to the characteristics and context of the individual migraine episode. Support for the viability of formulation-based, customized care comes from studies conducted in clinical practice, where patients given the flexibility to choose among triptan formulations to manage their migraines did not restrict themselves to one formulation but instead chose a formulation best suited to the characteristics of the individual migraine episode.[26, 27] The author acknowledges Jane Saiers, PhD (The WriteMedicine, Inc.), for assistance with writing the manuscript. Dr. Saiers’ work was funded by NuPathe Inc. “
“Objective.